Dizziness: A Diagnostic Approach

ROBERT E. POST, MD, Virtua Family Medicine Residency, Voorhees, New Jersey
LORI M. DICKERSON, PharmD, Medical University of South Carolina, Charleston, South Carolina

Dizziness accounts for an estimated 5 percent of primary care clinic visits. The patient history can generally classify
dizziness into one of four categories: vertigo, disequilibrium, presyncope, or lightheadedness. The main causes of ver-
tigo are benign paroxysmal positional vertigo, Meniere disease, vestibular neuritis, and labyrinthitis. Many medica-
tions can cause presyncope, and regimens should be assessed in patients with this type of dizziness. Parkinson disease
and diabetic neuropathy should be considered with the diagnosis of disequilibrium. Psychiatric disorders, such as
depression, anxiety, and hyperventilation syndrome, can cause vague
lightheadedness. The differential diagnosis of dizziness can be nar-
rowed with easy-to-perform physical examination tests, including
evaluation for nystagmus, the Dix-Hallpike maneuver, and ortho-
static blood pressure testing. Laboratory testing and radiography
play little role in diagnosis. A final diagnosis is not obtained in about
20 percent of cases. Treatment of vertigo includes the Epley maneu-
ver (canalith repositioning) and vestibular rehabilitation for benign
paroxysmal positional vertigo, intratympanic dexamethasone or
gentamicin for Meniere disease, and steroids for vestibular neuritis.

ILLUSTRATION BY TODD BUCK

Orthostatic hypotension that causes presyncope can be treated with
alpha agonists, mineralocorticoids, or lifestyle changes. Disequilib-
rium and lightheadedness can be alleviated by treating the underly-
ing cause. (Am Fam Physician. 2010;82(4):361-368. Copyright © 2010
American Academy of Family Physicians.)

D
Patient information: iagnosing the cause of dizzi- are not always consistent.6 Therefore, the
▲

A handout on dizziness, ness can be difficult because
written by the authors of
this article, is provided on symptoms are often nonspecific
page 369. and the differential diagnosis is
broad. However, a few simple questions and
physical examination tests can help narrow
the possible diagnoses. It is estimated that
primary care physicians care for more than
one half of all patients who present with dizzi-
ness.1 Dizziness is the chief presenting symp-
tom in about 3 percent of primary care visits
for patients 25 years and older, and in nearly 3
percent of all emergency department visits.2,3
Dizziness can be classified into four main
types: vertigo, disequilibrium, presyncope,
or lightheadedness. Although appropriate
history and physical examination usually
leads to a diagnosis, the final cause of diz-
ziness is not identified in up to one in five
patients.4,5
history should first focus on what type
of sensation the patient is feeling. Table 1
includes descriptors for the main categories
of dizziness.4,5,7,8 It is important to note that
some causes of dizziness can be associated
with more than one set of descriptors.
A medication history should be obtained
because dizziness (especially from ortho-
static hypotension) is a well-known adverse
effect of many drugs9 (Table 210,11). Patients
should also be asked about caffeine, nico-
tine, and alcohol intake.9 Head trauma and
whiplash injuries can cause a variety of dizzi-
ness symptoms, from vertigo to lightheaded-
ness. The incidence of dizziness with a head
injury or vertigo initially after whiplash have
been reported as high as 78 to 80 percent.12
Selected causes of dizziness are summarized
in Table 3.4,7,8,13-20

Patient History VERTIGO

The initial description of dizziness can be Otologic or vestibular causes of vertigo are
difficult to obtain because patient responses the most common causes of dizziness,21,22
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Dizziness
SORT: KEY RECCOMENDATIONS FOR PRACTICE Table 1. Main Categories of Dizziness
Evidence
Clinical recommendation rating References Percentage
of patients
The Dix-Hallpike maneuver should C 7, 9, 16 Category Description with dizziness
be performed to diagnose BPPV.
Vertigo False sense of motion, 45 to 54
Because they generally are not C 7, 31, 32
possibly spinning
helpful diagnostically, laboratory
sensation
testing and radiography are not
routinely indicated in the work- Disequilibrium Off-balance or wobbly Up to 16
up of patients with dizziness Presyncope Feeling of losing Up to 14
when no other neurologic consciousness or
abnormalities are present. blacking out
The Epley maneuver and vestibular B 40, 41, 42 Lightheadedness Vague symptoms, Approximately 10
rehabilitation are effective possibly feeling
treatments for BPPV. disconnected with
the environment
BPPV = benign paroxysmal positional vertigo.
A = consistent, good-quality patient-oriented evidence; B = incon- Information from references 4, 5, 7, and 8.
sistent or limited-quality patient-oriented evidence; C = consensus,
disease-oriented evidence, usual practice, expert opinion, or case
series. For information about the SORT evidence rating system, go
to http://www.aafp.org/afpsort.xml.
Table 2. Medications Commonly Associated
with Dizziness from Orthostatic Hypotension
and include benign paroxysmal positional vertigo
(BPPV), vestibular neuritis (viral infection of the vestib-
Cardiac medications
ular nerve), labyrinthitis (infection of the labyrinthine
Alpha blockers (e.g., doxazosin [Cardura], terazosin)
organs), and Meniere disease (increased endolymphatic
Alpha/beta blockers (e.g., carvedilol [Coreg], labetalol)
fluid in the inner ear).7,13 An estimated 35 percent of
Angiotensin-converting enzyme inhibitors
adults 40 years and older have vestibular dysfunction.14 Beta blockers
Hearing loss and duration of symptoms help nar- Clonidine (Catapres)
row the differential diagnosis further in patients with Dipyridamole (Persantine)
vertigo. Vertigo with hearing loss is usually caused by Diuretics (e.g., furosemide [Lasix])
Meniere disease or labyrinthitis, whereas vertigo with- Hydralazine
out hearing loss is more likely caused by BPPV or ves- Methyldopa
tibular neuritis.8 Unilateral auditory symptoms help Nitrates (e.g., nitroglycerin paste, sublingual nitroglycerin)
localize the cause to an anatomic abnormality, par- Reserpine
ticularly in patients with peripheral disease.9 Episodic Central nervous system medications
vertigo tends to be caused by BPPV or Meniere disease, Antipsychotics (e.g., chlorpromazine, clozapine [Clozaril],
whereas persistent vertigo can be caused by vestibular thioridazine)
neuritis or labyrinthitis.8 Opioids
Migrainous vertigo, or vestibular migraine, is another Parkinsonian drugs (e.g., bromocriptine [Parlodel], levodopa/
carbidopa [Sinemet])
underlying cause of vertigo that affects about 3 percent
Skeletal muscle relaxants (e.g., baclofen [Lioresal],
of the general population and about 10 percent of per- cyclobenzaprine [Flexeril], methocarbamol [Robaxin],
sons with migraine.15 This diagnosis should be consid- tizanidine [Zanaflex])
ered after other causes of vertigo have been ruled out. Tricyclic antidepressants (e.g., amitriptyline, doxepin, trazodone)
Diagnosis of migrainous vertigo is established in patients Urologic medications
with a history of episodic vertigo with a current migraine Phosphodiesterase type 5 inhibitors (e.g., sildenafil [Viagra])
or history of migraine and one of the following symp- Urinary anticholinergics (e.g., oxybutynin [Ditropan])
toms during at least two episodes of vertigo: migraine
Information from references 10 and 11.
headache, photophobia, phonophobia, or aura.15

PRESYNCOPE

Cardiovascular causes of dizziness include arrhythmias,
myocardial infarction, carotid artery stenosis, and ortho-
static hypotension.21 Of patients with supraventricular
tachycardia, 75 percent experience dizziness and about
30 percent experience syncope.23 Symptoms brought on
by postural changes suggest a diagnosis of orthostatic
hypotension.9 A variety of cardiovascular medications
increase the risk of orthostatic hypotension in older per-
sons, including reserpine (at doses greater than 0.25 mg),
doxazosin (Cardura), and clonidine (Catapres).24

362  American Family Physician www.aafp.org/afp Volume 82, Number 4 ◆ August 15, 2010
 Dizziness
Table 3. Selected Causes of Dizziness

Category
Cause of dizziness Pathophysiology Diagnostic criteria

Benign paroxysmal Vertigo Loose otolith in semicircular canals causing Positive findings with Dix-Hallpike
positional vertigo a false sense of motion maneuver; episodic vertigo without
hearing loss
Hyperventilation Lightheadedness Hyperventilation causing respiratory alkalosis; Symptoms reproduced with voluntary
syndrome underlying anxiety may provoke the hyperventilation
hyperventilation
Meniere disease Vertigo Increased endolymphatic fluid in the inner ear Episodic vertigo with hearing loss
Migrainous vertigo Vertigo Uncertain; one hypothesis is that trigeminal Episodic vertigo with signs of migraine,
(vestibular migraine) nuclei stimulation causes nystagmus in plus photophobia, phonophobia, or aura
persons with migraine during at least two episodes of vertigo
Orthostatic Presyncope Drop in blood pressure on position change Systolic blood pressure decrease of 20 mm
hypotension causing decreased blood flow to the brain, Hg, diastolic blood pressure decrease
adverse effect of multiple medications of 10 mm Hg, or a pulse increase of
(see Table 2) 30 beats per minute
Parkinson disease Disequilibrium Dysfunction in gait causing imbalance Shuffling gait with reduced arm swing
and falls and possible hesitation
Peripheral neuropathy Disequilibrium Decreased tactile response when walking Decreased sensation in lower extremities,
causes patient to be unaware when feet particularly the feet
touch the ground, leading to imbalance
and falls

Information from references 4, 7, 8, and 13 through 20.

DISEQUILIBRIUM findings than those without panic disorder.28 Up to

There are many underlying conditions that may cause
a sense of imbalance. Stroke is an important and life-
threatening cause of dizziness that needs to be ruled out
when the dizziness is associated with other symptoms of
stroke. However, other neurologic findings are generally
present. In a population-based study of more than 1,600
patients, 3.2 percent of those presenting to an emergency
department with dizziness were diagnosed with a stroke
or transient ischemic attack (TIA), but only 0.7 percent
presenting with isolated dizziness were diagnosed with
stroke or TIA.25
Poor vision commonly accompanies a feeling of imbal-
ance,16 leading to falls. The physician should inquire
about a history of other problems that may cause imbal-
ance, such as Parkinson disease, peripheral neuropathy,
and any musculoskeletal disorders that may affect gait.17
Use of benzodiazepines and tricyclic antidepressants
increase the risk of ataxia and falls in older persons.24
LIGHTHEADEDNESS
Psychiatric causes of lightheadedness are common,
particularly anxiety; therefore, questions about anxi-
ety and depression should be included in the patient
history. In one study, about 28 percent of patients with
dizziness reported symptoms of at least one anxiety
disorder.26 In another study, one in four patients with
dizziness met criteria for panic disorder.27 A study of
patients with chronic dizziness showed that those with
panic disorder were more likely to have neurotologic
60 percent of patients with chronic subjective dizziness
have been reported to have an anxiety disorder.29 Depres-
sion and alcohol intoxication have also been found to
overlap with dizziness.21,30
Hyperventilation syndrome is an important cause of
lightheadedness. Although the condition can be asso-
ciated with anxiety disorders, many patients without
anxiety experience hyperventilation. Hyperventilation
is defined as breathing in excess of metabolic require-
ments, causing a respiratory alkalosis and lighthead-
edness. Patients may sigh repeatedly and may have
associated symptoms, such as chest pain, paraesthesias,
bloating, and epigastric pain.18
Physical Examination
The main goal of the physical examination is to repro-
duce the patient’s dizziness in the office. There are a few
simple physical examination tests that can be performed
to aid in this goal.
First, blood pressure should be measured while the
patient is in a supine position and again at least one min-
ute after the patient stands. A systolic blood pressure
decrease of 20 mm Hg, diastolic blood pressure decrease
of 10 mm Hg, or pulse increase of 30 beats per minute is
indicative of orthostatic hypotension.16,19
The Dix-Hallpike maneuver (Figure 19,16) is diagnostic
for BPPV if positive, but does not rule it out if negative.
The maneuver is performed on a flat examination table.
While the patient is in a seated position, the physician

August 15, 2010 ◆ Volume 82, Number 4 www.aafp.org/afp American Family Physician  363
 45°
ILLUSTRATION BY MARCIA HARSTOCK

A B

Figure 1. Dix-Hallpike maneuver. While the patient is in a seated position, the physician (A) turns the patient’s head
45 degrees to one side, then (B) rapidly lays the patient into a supine position with the head hanging about 20 degrees
over the end of the table, observing the patient’s eyes for approximately 30 seconds. The maneuver is repeated for
the opposite side. Nystagmus is diagnostic of vestibular debris in the ear that is facing down, closest to the examina-
tion table. A video demonstration of this maneuver is available at http://www.youtube.com/watch?v=vRpwf2mI3SU.
Information from references 9 and 16.

turns the patient’s head 45 degrees to one side, then rap-
idly lays the patient into a supine position with the head
hanging about 20 degrees over the end of the table and
observes the patient’s eyes for approximately 30 seconds.
The maneuver is repeated with the head turned to the
opposite side. Nystagmus is diagnostic of vestibular debris
in the ear that is facing down, closest to the examination
table. There is usually a latent period of a few seconds
before the patient develops nystagmus, and a sensation
of vertigo for up to one minute.9,16 The sensitivity of the
Dix-Hallpike maneuver is 50 to 88 percent for BPPV.7
Lesions of the labyrinth and cranial nerve VIII (vestib-
ulocochlear) commonly produce spontaneous nystag-
mus. Saccadic eye movements associated with a patient’s
smooth ocular pursuit of the physician’s finger as it
moves slowly left, right, up, and down may be associated
with a central cause, such as brainstem or cerebellar dis-
ease. The head impulse test involves asking the patient
to remain focused on a target while the physician moves
the patient’s head back and forth rapidly. Eye movement
to one side with a refixation saccade (rapid oscillatory
eye movement that occurs as the eye fixes on an object)
is indicative of a lesion on the side to which the eyes
move. Bilateral refixation movements commonly occur
with ototoxicity. Another test that can elicit nystagmus
involves the patient leaning forward 30 degrees while the
physician shakes the patient’s head back and forth vigor-
ously for 20 seconds. The presence of nystagmus indi-
cates a peripheral cause in the ipsilateral direction of the
nystagmus.9
Other physical examination tests include the Romberg
test and observation of gait. Swaying toward one side
with the Romberg test is indicative of vestibular dysfunc-
tion in the ipsilateral side. Also, a patient’s gait will lean
toward the side of a vestibular lesion. Ataxia is indicative
of cerebellar dysfunction, and the patient’s gait is usually
slow, wide-based, and irregular.9,20 Observation of gait
is also important to detect symptoms suggestive of par-
kinsonism in patients presenting with disequilibrium.4
In early Parkinson disease, gait is usually slower with
smaller steps and reduced arm swing, and progresses
to freezing and hesitation in later stages of the disease.20
Screening for peripheral neuropathy is also important in
patients presenting with disequilibrium.4
If hyperventilation syndrome is suspected, the diag-
nosis can be confirmed by having the patient rapidly
take 20 deep inhalations and exhalations, in an attempt
to reproduce symptoms.9,18
A thorough cardiovascular examination should be
performed in all patients with dizziness. However, tests
such as electrocardiography, Holter monitor testing, and
carotid Doppler testing should be performed only if an
underlying cardiac cause is suspected based on other
findings or known cardiac disease.7
Additional Testing
In general, laboratory testing and radiography are not
beneficial in the work-up of patients with dizziness
when no other neurologic abnormalities are present.31,32
Laboratory studies, including complete blood count,

364  American Family Physician www.aafp.org/afp Volume 82, Number 4 ◆ August 15, 2010
 Dizziness
Approach to the Patient with Dizziness
Patient presents with dizziness

Ask about medication regimen; caffeine, nicotine, and

alcohol intake; and history of head trauma or whiplash

What sensation does the patient describe?

False sense of motion Off-balance or wobbly Feeling of losing Vague symptoms,

or spinning sensation consciousness possibly feeling
or blacking out disconnected with
Dysequilibrium the environment
Vertigo
Presyncope
Consider possible underlying Lightheadedness
conditions, such as
peripheral neuropathy and Ask about history
Ask about migraine symptoms
Parkinson disease of arrhythmias and Ask about history of
Recheck medication regimen, myocardial infarction anxiety or depression
especially in older patients Recheck medication Perform hyperventilation
Migrainous vertigo is diagnosed with history of
Examine gait and vision, regimen, especially provocation test
episodic vertigo with a current migraine or history
perform Romberg test, in older patients
of migraine and one of the following symptoms
during at least two episodes of vertigo: migraine screen for neuropathy Measure orthostatic
headache, photophobia, phonophobia, aura blood pressures

Hearing loss?
Consider cardiac
testing in patients
Yes No with relevant history

Episodic vertigo? Episodic vertigo?

Yes No Yes No

Meniere Labyrinthitis Benign paroxysmal Vestibular

disease positional vertigo neuritis

Perform Dix-Hallpike maneuver (Figure 1)

Figure 2. Algorithm for the initial evaluation of a patient with dizziness.

metabolic panels, and thyroid function tests, have very
low yield in diagnosing a cause of dizziness. In one
meta-analysis, only 26 of 4,538 patients (0.6 percent) had
laboratory abnormalities that explained their dizziness.7
Electronystagmography tests vestibular function by
using electrodes to detect nystagmus. The test has a
reported sensitivity of 69 to 74 percent and specificity
of 81 to 83 percent for peripheral vestibular disorders.
For central vestibular disorders, sensitivity has been
reported as high as 81 percent and specificity as high as
93 percent.7
Approach to the Patient
After obtaining the patient history, the physician can tai-
lor the physical examination to best fit the differential
diagnosis. One approach to the initial evaluation of
patients with dizziness is presented in Figure 2.
The initial history can help place the diagnosis into one
of the four major categories of dizziness. Then, questions
specific to that category can further narrow the possible
diagnoses. A thorough neurologic and cardiovascular
examination should be performed in all patients, as well
as targeted components of the physical examination
based on suspicion of the underlying diagnosis. Further
testing, such as cardiac and radiologic testing, is only
needed when specific causes are suspected.
Treatment of vertigo has been addressed.33 Table 4
summarizes the treatment of selected causes of dizzi-
ness,10,18,34-49 and Figure 3 illustrates the Epley maneuver,
an effective treatment for BPPV.41

August 15, 2010 ◆ Volume 82, Number 4 www.aafp.org/afp American Family Physician  365
Table 4. Treatment for Selected Causes of Dizziness
Cause Treatment
Vertigo
Benign paroxysmal Meclizine (Antivert), 25 to 50 mg orally
positional vertigo every four to six hours
Epley maneuver (canalith repositioning;
see Figure 3)
Vestibular rehabilitation
Meniere disease Salt restriction (less than 1 to 2 g of
sodium per day) and/or diuretics
(most commonly, hydrochlorothiazide/
triamterene [Dyazide])
Intratympanic dexamethasone or
gentamicin
Endolymphatic sac surgery
Vestibular neuritis Methylprednisolone (Depo-Medrol),
initially 100 mg orally daily then tapered
to 10 mg orally daily over three weeks
Migrainous vertigo Migraine prophylaxis with serotonin 5-HT1
receptor agonists (triptans)
Presyncope
Orthostatic Review medication regimen
hypotension
Midodrine (Proamatine) titrated up to
10 mg orally three times daily
Fludrocortisone, initially 0.1 mg orally
daily, titrated up weekly until peripheral
edema develops or to a maximal dosage
of 1 mg daily
Pseudoephedrine, 30 to 60 mg orally daily
Paroxetine (Paxil), 20 mg orally daily
Desmopressin (DDAVP), 5 to 40 mcg
intranasally daily
Disequilibrium Treatment of underlying cause
(e.g., peripheral neuropathy,
Parkinson disease)
Lightheadedness
Hyperventilation Breathing control exercises, rebreathing
syndrome into a small paper bag
Beta blockers
Antianxiety agents (e.g., selective
serotonin reuptake inhibitors) or short-
term use of benzodiazepines
RCT = randomized controlled trial.
Information from references 10, 18, and 34 through 49.
Comments
Commonly used to reduce symptoms of acute episodes of vertigo,
although there are no RCTs to support its use; use of vestibular
suppressants can lead to brainstem compensation and prolong
vertiginous symptoms
Main benign paroxysmal positional vertigo treatment; safe and
effective compared with placebo; video demonstration is available
at http://www.youtube.com/watch?v=ZqokxZRbJfw&NR=1
Series of head and neck exercises that can be performed daily at
home; video demonstration available at http://www.youtube.com/
watch?v=hhinu_oU_hM
Evidence for balance therapy (e.g., tai chi, Wii Fit) is accumulating
No large-scale RCTs to support these therapies
Referral to an otolaryngologist required; in one small study,
dexameth­asone resolved symptoms in 82 percent of patients; in
a larger study, gentamicin resolved symptoms in 80.7 percent of
patients 46,47
Referral to an otolaryngologist required
In an RCT, methylprednisolone was more effective in improving
peripheral vestibular function than valacyclovir (Valtrex) in patients
with vestibular neuritis 49
Treatment based on expert opinion, not RCTs
This is the first step, especially in older patients; rehydration (even
increased water intake) can improve symptoms, especially in those
with autonomic failure
Alpha-1 agonist metabolite; to avoid supine hypertension, the third
dose should be given by 6 p.m.; should be used only in severely
impaired patients; in placebo-controlled trials, midodrine was
associated with increased standing blood pressures and fewer
orthostatic symptoms compared with placebo36
Mineralocorticoids, such as fludrocortisone, are used to increase
sodium and water retention; monitor blood pressure, potassium
level, and for symptoms of heart failure
Fludrocortisone and midodrine can be used in combination if either
agent alone fails to control symptoms
These drugs are options when midodrine and fludrocortisone are
ineffective
Nondrug therapy includes replacement of fluids, rising slowly
from lying or sitting positions, sleeping with the head of the bed
elevated, increasing salt intake, and regular exercise
Because disequilibrium is generally a symptom of an underlying
condition, treatment of the condition improves symptoms of
disequilibrium
Reverses hypocapnia-related symptoms
Treats associated symptoms, such as palpitations and sweating; not
for use in patients with asthma
For use in patients with underlying anxiety
 45°

A B

90°

ILLUSTRATION BY MARCIA HARSTOCK

90°

C D

Figure 3. Epley maneuver (canalith repositioning). The

technique involves a series of movements. (A) The maneu-
ver begins with the patient sitting with the head rotated
45 degrees to the right. (B) The physician lays the patient
into a supine position with the head hanging over the
end of the table. (C) The head is then rotated 90 degrees
to the left, (D) and the head and body are rotated
together an additional 90 degrees until the patient is 135
degrees from the initial supine position. (E) The patient
is brought to a sitting position while the head remains
tilted. Finally, the head is brought forward and downward
to an angle of 20 degrees. The physician should pause at
each position until nystagmus resolves, and the whole
series should be repeated until no nystagmus is present
at any position. The maneuver can also begin with the
patient in the supine position. A video demonstration of
this maneuver is available at http://www.youtube.com/
watch?v=ZqokxZRbJfw&NR=1.
E
Information from reference 41.

Address correspondence to Robert E. Post, MD, 2225 Evesham Rd., Suite

The Authors
ROBERT E. POST, MD, is a faculty member with the Virtua Family Medicine
Residency in Voorhees, N.J. At the time this article was written, he was an
instructor in the Department of Family Medicine at the Medical University
of South Carolina in Charleston.
LORI M. DICKERSON, PharmD, is a professor in the Trident Medical
Center/Medical University of South Carolina Family Medicine Residency
Program.
101, Voorhees, NJ 08043 (e-mail: rpostmd@gmail.com). Reprints are
not available from the authors.
Author disclosure: Nothing to disclose.
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